Provider Demographics
NPI:1053565648
Name:MACTA, LLC
Entity type:Organization
Organization Name:MACTA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:W
Authorized Official - Last Name:WOOTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-443-0836
Mailing Address - Street 1:1012 SANDBERG LN
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27803-2253
Mailing Address - Country:US
Mailing Address - Phone:252-443-0836
Mailing Address - Fax:252-443-0836
Practice Address - Street 1:450 S WESLEYAN BLVD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27803-1700
Practice Address - Country:US
Practice Address - Phone:252-443-0836
Practice Address - Fax:252-443-0836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-09
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health